Home Health & Hospice Week

Will the initiative harm innocent DME bystanders?

A sharp increase in power wheelchair spending coupled with a proliferation of wheelchair "scams" have led to a new aggressive initiative to curb fraud and abuse of the Medicare program. But industry experts worry the measure could punish durable medical equipment suppliers who play by the rules.

The Centers for Medicare & Medicaid Services and the HHS Office of Inspector General announced the 10-point fraud-fighting plan, dubbed "Operation Wheeler Dealer," Sept. 9 (see story, "Fraud-Fighting Plan Requires...."). Medicare power wheelchair spending has jumped 450 percent in just four years, the feds noted in their announcement.

The launch comes on the heels of an investigation of fraudulent wheelchair suppliers in the Houston area. "In Harris County, Texas alone, Medicare paid for more than 31,000 power wheelchairs in 2002, compared to just over 3,000 power wheelchairs in 2001," the agencies noted.

"This abuse is an insult to all Americans who pay taxes. It's got to stop," said CMS chief Tom Scully. "Our 10-point campaign is an aggressive way to end this exploitation of the Medicare program."

Industry representatives are quick to applaud the feds' fraud-fighting zeal. "We want these fly-by-night companies out of the program," says attorney Steve Azia, counsel to the Power Mobility Coalition.

"There should be zero tolerance for Medicare fraud and abuse involving power wheelchairs," adds the American Association for Homecare.

But reps worry the feds' enthusiasm for curbing fraud and abuse could unintentionally harm innocent DME bystanders. "We urge caution in implementing this new initiative," AAH says. "Law-abiding providers work hard to serve Medicare beneficiaries in their communities and they should not be unfairly penalized."

"Suppliers who play by the rules shouldn't be punished," agrees Azia, with Eastood & Azia in Washington, DC. "We don't want an overreaction" on the feds' part, he tells Eli.

Financial, False Claims Risk Increases

The campaign should come as no surprise to the DME industry, notes attorney Gabe Imper-ato with Broad and Cassel in Ft. Lauderdale, FL. The dramatic increase in power wheelchair spending has had the feds murmuring about fraud-fighting action for a while, Imperato says.

The initiative will mean greater scrutiny than ever before for power wheelchair claims, as well as the suppliers who submit them. Medicare, the OIG, the DME regional carriers and state agencies all will be placing wheelchair claims under an especially strong microscope, experts say.

And some new parties likely will be sticking their noses in as well - U.S. Attorneys and whistleblowers looking to "cash in" on the power wheelchair development, Imperato predicts.

The result will be greater risk for suppliers who provide power wheelchairs, warns attorney Robert Falk with the Washington, DC office of Powell Goldstein Frazer & Murphy. Financial risk and risk of potential False Claims Act charges will increase with this campaign, Falk expects.

If investigators' efforts are overzealous, suppliers could find themselves on the hook for False Claims Act charges when all they really had was a claim lacking sufficient documentation, Falk worries. He hopes the feds remember that an under-documented claim is not the same as a false claim.

"This raises the stakes for supplying these items," Imperato surmises. In the new enforcement climate, simple sales and promotion of power wheelchairs may be construed as fraudulent.

10-Point Plan Harries Suppliers

Some of the specific components of the 10-point plan will make life harder for wheelchair suppliers, experts forecast. For example, CMS says it will freeze new supplier number issuances so it can  "begin aggressively scrutinizing all new applications." Early 2004 is the soonest new supplier numbers will be awarded, CMS says.

"This could be a concern for legitimate enterprises" that are trying to launch their Medicare businesses, Falk tells Eli. Because suppliers generally don't state in their applications what type of equipment they'll be furnishing, the freeze is likely to affect all suppliers, not just those that provide power wheelchairs, he points out.

Azia heralds the feds' promise of consistent medical review from the DMERCs. "That's a great concept," he says. But if the carriers adopt medical review policies that are too stringent, it will harm suppliers.

And if the DMERCs neglect to tell suppliers what the medical review parameters are, suppliers will suffer, Falk stresses. In that scenario, the DMERCs would punish providers for what they deem is poor documentation, but won't tell you ahead of time what that documentation should be.

Another concern is the feds' vow to issue new coverage regulations for motorized wheelchairs and scooters, Azia says. The effect on suppliers will depend on what that new coverage policy contains.

In fact, much of the plan's impact is unclear until the feds and DMERCs issue more specific information on each of the points, Azia observes. "The devil is in the details."

"This is a plan to make a plan," Falk agrees. The feds have "the opportunity to do things right," he notes. But if they fail to share information and specifics with the supplier community, the results could be damaging.

The feds maintain the initiative won't be an undue burden on suppliers who comply with the rules. "Under the campaign ... Medicare will be able to support honest providers and target those who are exploiting the program," the announcement says.